CardioBuzz: Dueling Guidelines

The National Lipid Association went a different way on cholesterol treatment targets. Here's why.

In this guest blog, Terry A. Jacobson, MD, president of the National Lipid Association, explains why his organization, in its recent cholesterol guidelines, went a different way on cholesterol treatment targets than the American Heart Association (AHA) and the American College of Cardiology (ACC).

Jacobson also serves as director of the Office of Health Promotion and Disease Prevention at Emory University in Atlanta.

The successful management of cholesterol and heart disease risk requires an approach that recognizes the uniqueness of each individual, including risk factors for heart disease and stroke, family history, lifestyle and other behaviors, and the willingness to make healthy changes. Patients must work with healthcare providers in active partnership to achieve success in reducing their risk of heart disease and stroke.

This is where the National Lipid Association's (NLA) new recommendations have an important role to play, as a complement to the 2013 AHA-ACC guidelines.

Based only on the interpretation of randomized, controlled trials of statin cholesterol-lowering therapy, the AHA-ACC guidelines removed the importance of patients achieving cholesterol targets and de-emphasized the frequent monitoring of LDL cholesterol. The emphasis was on whether a patient is taking a statin and not necessarily how he or she is responding to statin therapy.

As both a physician and a patient, I have always been of the belief to first trust a patient in what they say, but then to verify what they have actually done. Therefore, the monitoring of LDL cholesterol and setting of cholesterol goals have always been the divining rod of not only how effective the therapy is, but whether a patient is actually complying.

Because of this, many of us at the NLA strongly believe that LDL monitoring and target goals are crucial in the patient-centric management of high cholesterol. Quite simply, this is one of the best tools that healthcare providers have -- it is easily understood by patients, is actionable, and is clearly related to long-term adherence and better heart and stroke outcomes.

In healthcare, we've spent the last several decades telling patients, "Know your cholesterol," "Know your lipids," "Monitor your weight and physical activity and limit saturated and trans-saturated fats in your diet," "If you don't have a good cholesterol response, you may need to go on a medicine like a statin."

By de-emphasizing LDL monitoring and cholesterol targets, the new guidelines -- however inadvertently -- have reduced the importance of the patient-physician relationship by removing their only tool to measure success. With the cholesterol goals to aim for, patients were able to ask their doctors, "How am I doing? I've made lifestyle changes; I'm taking my drug. Am I hitting my cholesterol target?"

If we do not provide a metric of what patients should be shooting for, they cannot know if they are successful.

The new guidelines send the message: "If you're taking a statin at a moderate or high dose, then you are successful." But what does that really mean to a patient; and how does a practitioner effectively translate that to the patient? A patient wants to know "Where did my cholesterol begin? Where is it now? Am I being successful at controlling it?"

In short, with the new NLA recommendations we want to put the metric of measuring LDL cholesterol and target cholesterol back on the map.

The new guidelines, in their intention to be very evidence-based, removed one of the most important aspects of the patient-physician relationship: communicating about lifestyle, diet, physical activity, and what to do about the barriers to achieving cholesterol goals. And, in fact, the lack of LDL monitoring or targets in the AHA-ACC guidelines may lead to unanticipated consequences such as a decrease in patient compliance with evidence-based therapies.

We would like to get back to more "patient-centered" treatment and what was working before -- i.e., talking to patients about their individual goal for LDL cholesterol and how they can get there with diet and lifestyle adjustment, as well as drug therapy.

We think it's important that patients know when they are successful. Otherwise, that's like someone running up and down a football field but not knowing where the goal line is, and that's not something that serves anyone. We want to be able to clearly communicate to patients that if they've attained a certain cholesterol level they have done what they can to reduce their risk of heart disease and stroke.

The AHA-ACC guidelines categorize patients as falling into one of four "statin benefit groups." This is a simple and clear distinction, but in our minds it is a faulty framing device -- it puts the emphasis on statins rather than on what individual patients need to do to reduce their risk of heart attacks and stroke.

In lay parlance, if all you have is a hammer then everything looks like a nail. Although statins are quite effective hammers in reducing the risk of heart attack and stroke, patients are not nails and are unique in their beliefs, family history, risk factors, and desire to take a medication for life. The emphasis on "statinization" of patients leads to the further "medicalization" of care, thus eroding the personal treatment that providers are attempting to give and the care that patients want to receive and that they deserve.

Medicines are certainly not the only way to go in terms of reducing patient risk, and this framework tends to narrow the choices needed to work in partnership. We recommend a more holistic, comprehensive approach to managing and treating risk.

It is our greatest hope that the NLA recommendations will help providers and patients better understand their options in achieving patient-centered cholesterol management. It is important to still use metrics of success such as getting frequent cholesterol testing and aiming for a target.

We're not even suggesting the target must be the optimal cholesterol level; it could be anything that allows patients to know if they've succeeded or not -- similar to a weight target, a blood pressure target, or even the number of minutes per day of moderate physical activity.

Without the humanizing presence of a goal or target for patients to aim for, the entire process becomes too academic and removed for patients to fully engage, both with their provider and for their own best health.

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